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ORIGINAL ARTICLE
Year : 2019  |  Volume : 25  |  Issue : 4  |  Page : 177-179

Topical silver nitrate application during myringoplasty for large tympanic membrane perforation


Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission03-Oct-2018
Date of Acceptance11-Jan-2019
Date of Web Publication4-Dec-2019

Correspondence Address:
Dr. Ibrahim Mohammad Saber
Department of Otorhinolaryngology.Head and Neck Surgery, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/indianjotol.INDIANJOTOL_89_18

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  Abstract 


Objective: The aim of this study was to assess the topical application of silver nitrate during myringoplasty for large tympanic membrane (TM) perforation. Patients and Methods: This study was applied on 70 patients who had large dry central TM perforations. The patients were randomly divided into two groups: silver nitrate group for whom silver nitrate 50% was used during myringoplasty and control group that was managed traditionally without silver nitrate. The patients were evaluated on the basis of postoperative graft taking, hearing improvement, and complications. Results: Both groups were statistically matched with regard to age and sex. At 6 months postoperatively, success rate (graft taking) in silver nitrate group was 88.57% and 82.86% in control group with statistically nonsignificant difference (P = 0.49). Success in terms of hearing gain (≥10 dB) was achieved in 23 patients (65.6%) in the silver nitrate group and 12 patients (34.4%) in the control group with statistically nonsignificant difference (P = 0.079). Conclusion: Topical application of 50% silver nitrate during myringoplasty for large TM perforations is safe, provides refreshing the edges of the large TM perforation, and avoids losing any part of the precious remnants of the large TM perforation.

Keywords: Hearing loss, myringoplasty, perforation, silver nitrate, tympanic membrane


How to cite this article:
El-Anwar MW, AbdElbary ME, Saber IM, Elshora ME, Hosny SM. Topical silver nitrate application during myringoplasty for large tympanic membrane perforation. Indian J Otol 2019;25:177-9

How to cite this URL:
El-Anwar MW, AbdElbary ME, Saber IM, Elshora ME, Hosny SM. Topical silver nitrate application during myringoplasty for large tympanic membrane perforation. Indian J Otol [serial online] 2019 [cited 2020 Jul 2];25:177-9. Available from: http://www.indianjotol.org/text.asp?2019/25/4/177/272258




  Introduction Top


Tympanic membrane (TM) perforation leads to decreased hearing recurrent middle ear infection and may lack of participation in water sports.[1] Large TM perforations represent a challenge during tympanoplasty because poorer results are obtained for larger perforations than that of the results obtained for small perforations.[2],[3],[4],[5]

The principle of chemical cauterization is that after application, it breaks up fibrosis and promotes granulation and new tissue formation at the margin of the perforation.[5]

The first recorded use of silver nitrate chemical cautery to stimulate the closure of TM perforations was carried out in 1848.[6] Derlacki reported a 75% closure rate in 1227 patients by an average of >14 office settings.[7] Silver nitrate (10%) was used by the same authors as an office procedure for the management of small perforations with closure rate 76.9%.[8]

The aim of this study was to assess topical silver nitrate (50%) application for trimming of perforation edge during myringoplasty for large TM perforation.


  Patients and Methods Top


This study was carried out on patients scheduled for myringoplasty in the period from October 2014 to April 2017. All patients had large dry central TM perforation and apparently healthy middle ear mucosa at least for 3 months before surgery. The TM was divided preoperatively into four quadrants and only large perforations involving >2 quadrants[5],[9] were included in the study.

Patients present with active ear discharge and cholesteatoma, patients who underwent any type of mastoidectomy, and those with suspected ossicular pathology (>40 dB air-bone gap [ABG])[8],[9] were excluded from the study. Patients who did not complete follow-up were also excluded from the study. Informed written consent was obtained from all patients.

The patients were randomly categorized into two groups: silver nitrate group for whom silver nitrate 50% in a solution form was topically applied and control group that was managed traditionally without silver nitrate.

Under general anesthesia, myringoplasty was done using postauricular approach, underlay technique, and conceal perichondrium graft in all cases.

Cautery of the tympanic membrane perforation edges by silver nitrate 50% in group (A)

It was started first by applying a piece of cotton medial to the TM to completely cover the middle ear mucosa to avoid its exposure to the silver nitrate solution during cauterization. Then, a cotton-tipped prop soaked by silver nitrate 50% in a solution form was used to cauterize the outer layer of the edge of the TM perforation till blanching was seen all around the rim. The edge of the mucosal layer of the TM perforation was also cauterized using round knife soaked with silver nitrate 50% solution. Hence, the edge of the TM perforation was refreshed chemically not surgically nearly without losing any part of the TM perforation edges. Then, the cotton placed formerly in the middle ear was removed.

In the control group, refreshing of the TM perforation edges was performed surgically by needle trimming and removal of about 1 mm of the edges all around.

In all cases of both groups, through postauricular approach, tympanomeatal flap was elevated and the perichondrial graft was inserted, adjusted, and supported by Gelfoam. Two packs were left in the external auditory canal; the postauricular incision was sutured in layers. Pressure dressing was left over the operated ear for 1 week.

Patients of both groups were discharged in the same day of surgery. Broad-spectrum systemic antibiotic was described for 1 week. The stitches and the outer pack were removed 1 week postoperative, topical antibiotic ear drops were applied for 2 weeks and then, the inner pack was removed 2 weeks postsurgery.

The patients in this study were evaluated on the basis of postoperative graft taking, hearing improvement, and complications. Successful closure of perforation was defined as an intact TM at 6 months postoperatively.[5] Success in terms of hearing was defined as an improvement of 10 dB or greater at 6 months.[5],[10],[11] Operative duration was calculated from the skin incision to the last skin closure suture.

Statistical analysis

Statistical analyses were performed using SPSS 17 statistical software for Windows (SPSS Inc., Chicago, IL, USA). The significance level was set at P < 0.05.


  Results Top


Seventy patients who had large central dry TM perforation caused by tubotympanic chronic suppurative otitis media (CSOM) were included in this study, 18 males (51.14%) and 17 females (48.57%) in the silver nitrate group and 16 males (45.7%) and 19 females (54.28%) in the control group. The mean age was 26.5 ± 19.1 for silver nitrate group and 22.9 ± 15.1 for the control group. Both groups were matched with regard to sex (P = 0.81) and age (P = 0.3848) [Table 1].
Table 1: Comparison between the studied groups regarding age, sex, and side of surgery

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The follow-up ranged from 6 to 14 months. At 6 months postoperatively, success rate (in terms of graft take) in the silver nitrate group was 88.57% that was insignificantly higher than that of the control group (82.86%) (P = 0.494). Success in terms of hearing gain (≥10 dB) revealed that in the silver nitrate group, success was achieved in 23 patients (65.6%) that is better than the success achieved in the control group (12 patients, 34.4%) with nonquite statistically significant difference (P = 0.079) [Table 2].
Table 2: Success rates according to graft take and hearing gain

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Preoperative mean of ABG in the silver nitrate group was 22.5 ± 10.6 and in the control group was 22.3 ± 8.7 with nonsignificant difference (P = 0.9315). While postoperative mean of ABG was 13.5 ± 19.1 in the silver nitrate group and 14.8 ± 9.2 in the control group without statistically significant difference (P = 0. 7179) [Table 2].

No graft was lateralized or displaced into the middle ear, and no retraction pocket was observed during the follow-up period. There were no postoperative complications such as sensorineural hearing loss (SNHL), tympanosclerosis, thin atrophic TM areas, granulation, or infection.

The mean operative duration was 71.7 ± 1.3 in the silver group and 83.2 ± 2.1 in the control group with highly significant difference (P < 0.0001).


  Discussion Top


The aim of myringoplasty is to prevent recurrent ear discharge and to improve hearing impairment caused by TM perforation.[11],[12]

Chemical cautery was previously used by silver nitrate or trichloroacetic acid. The first recorded use of silver nitrate for TM perforations was carried out by Wilde and Hewson in 1848.[6]

Removal of 1 mm from the edge of the perforation for trimming increases the perforation size and this increase may eventually lead to loss of the edge particularly anterior, adding to the difficulties of the procedure.

In this study, we assess a new technique by avoiding surgical trimming of the TM perforation, and instead, we cauterized the edges of the TM perforation preserving almost all parts of the TM remnants thus facilitating graft insertion and adjustment under the perforation edge all around.

This technique is done under general anesthesia as silver nitrate used in high concentration (50%) to avoid irritation and pain to the patients. Postauricular approach was used because the perforations were large to provide better exposure during the surgery.

In this study, success rate (graft taking) in the silver nitrate group (88.57%) was insignificantly higher than that of the control group (82.86%) (P = 0.494) without reported complications.

The mean operative duration was significantly shorter in the silver group than that of the control group (P < 0.0001) reflecting less technical difficulties with silver cauterization of the edge that allows preserving the edge facilitating graft insertion and adjustment. These results prove the effective role of silver nitrate cauterization during myringoplasty for large TM perforation that could be beneficial in limiting the challenges of losing the TM remnants after its surgical traditional trimming. In addition, such achieved advantages with silver nitrate usage could help resident training for myringoplasty.

Although silver nitrate had been used for the repair of small TM perforations as an office procedure,[8] this study is the first clinical study of topical application of silver nitrate during the repair of large TM perforation caused by CSOM and proved to have a beneficial effect on duration of surgery but without a significant increase in success.

The current method is safe without reported SNHL, granulations, or infection. In addition, it preserved almost all the residual parts of the perforated TM thus making identification of the perforation edge particularly anterior easier facilitating the procedure and allows easy exposure during the surgery. This facilitates to provide good support to the graft solving the main obstacles of grafting the large TM perforations.


  Conclusion Top


Topical application of 50% silver nitrate during myringoplasty for large TM perforations is safe and successful with no reported complications because silver nitrate not only provides refreshing the edges of the large TM perforation but also avoids losing any part of the precious remnants of the large TM perforation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Uppal KS, Singh R, Singh J, Popli SP. Closure of tympanic membrane perforations by chemical cautery. Indian J Otolaryngol Head Neck Surg 1997;49:151-3.  Back to cited text no. 1
    
2.
Lee P, Kelly G, Mills RP. Myringoplasty: Does the size of the perforation matter? Clin Otolaryngol 2002;27:331-4.  Back to cited text no. 2
    
3.
Albu S, Babighian G, Trabalzini F. Prognostic factors in tympanoplasty. Am J Otol 1998;19:136-40.  Back to cited text no. 3
    
4.
Sade J, Berco E, Brown M, Weinberg J, Avraham S. Myringoplasty in children: short and long term results in a training program. J Laryngol Otol 1981;95:653-5.  Back to cited text no. 4
    
5.
El-Anwar MW, El-Ahl MA, Zidan AA, Yacoup MA. Topical use of autologous platelet rich plasma in myringoplasty. Auris Nasus Larynx 2015;42:365-8.  Back to cited text no. 5
    
6.
Scaramella LF, Farrell BP, Kooiker PD, Marra S. Effectiveness of nonsurgical office closure of tympanic membrane pars tensa perforations. Ear Nose Throat J 2002;81:556-8, 560.  Back to cited text no. 6
    
7.
Diamant H, Hultcrantz M. Glimpses from the history of otitis media. Nord Medicinhist Arsb 1996;189-95.  Back to cited text no. 7
    
8.
Derlacki EL. Office closure of central tympanic membrane perforations: A quarter century of experience. Trans Am Acad Ophthalmol Otolaryngol 1973;77:ORL53-66.  Back to cited text no. 8
    
9.
El Anwar MW, Abd Elbary ME, Saber IM. Silver cauterization: An office procedure for repair of small tympanic membrane perforation. Indian J Otol 2017;23:17-20.  Back to cited text no. 9
    
10.
Saliba I. Hyaluronic acid fat graft myringoplasty: How we do it. J Compilation Clin Otolaryngol 2008;33:607-28.  Back to cited text no. 10
    
11.
Sergi B, Galli J, De Corso E, Parrilla C, Paludetti G. Overlay versus underlay myringoplasty: Report of outcomes considering closure of perforation and hearing function. Acta Otorhinolaryngol Ital 2011;31:366-71.  Back to cited text no. 11
    
12.
Hosny S, El-Anwar MW, Abd-Elhady M, Khazbak A, El Feky A. Outcomes of myringoplasty in wet and dry ears. Int Adv Otol 2014;10:256-9.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Patients and Methods
Results
Discussion
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References
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